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Ellipse, Ellipse Variations, and Dog-ear Repairs

Chapter Summary The best results in ellipse excision are achieved by: designing the simplest repair that will achieve optimal cosmesis avoiding unnecessary flaps or grafts undermining only as needed. The repair type is selected according to patient characteristics and clinical circumstance, including: consideration of the patient's age, health, and level of activity consideration of second intention healing if cosmetic outcome is likely to be superior to…

Hemostasis

Chapter Summary Physiologic hemostasis occurs in three interrelated phases: initiation (thrombin formation); amplification (platelet aggregation and activation); and propagation (fibrin formation and clot stabilization). In general, anticoagulation prescribed for secondary thrombotic prophylaxis should not be discontinued for dermatologic surgery procedures. Optimizing anesthesia, and alleviating anxiety and situational hypertension, will significantly reduce the risk of perioperative bleeding. Use of an electronic scalpel for cutting and aspiration are…

Complex Layered Facial Closures

Chapter Summary Facial skin is divided into discrete cosmetic subunits whose aesthetic characteristics are derived from regional variations in the composition of the underlying tissue layers. Careful attention to restoring these subunits during reconstruction is critical. The human face is composed of an interrelated functional unit of muscle, connective tissue, and overlying skin that should be treated as a single unit to obtain optimal results. Layered…

Suturing Technique and Other Closure Materials

Chapter Summary Choice and placement of wound closure materials play critical roles in the outcome of incisional surgery. The properties of suture materials combine to give each suture unique characteristics. Sutures must be placed at the same vertical level across the wound to prevent step-off deformity of the incision. Proper placement of sutures will approximate and evert wound edges. Buried sutures are used to close dead…

Incision, Draining, and Exteriorization Techniques

Chapter Summary Preoperative planning includes the following methods to confirm and define the extent of the condition: using palpation, ultrasonography (US), computed tomography (CT) or magnetic resonance imaging (MRI). Be mindful of the regional anatomy. Previously removed cysts may be surrounded by fibrotic scar tissue. Methods of anesthesia, such as topical and local anesthesia (including tumescent anesthesia), nerve block, and general anesthesia, should be considered. Prior…

Skin Biopsy Techniques

Chapter Summary The skin biopsy is essential to dermatologic surgery both in diagnosis and planning therapy. Several biopsy techniques are available, including shave, saucerization, curettage, scissors “snip,” punch, and scalpel excision, or incisional biopsy. Complications are infrequent but can be minimized by careful preoperative evaluation for risk factors and by meticulous technique. The biopsy site should be selected carefully taking into account factors likely to give…

Cryosurgery

Chapter Summary A surgical treatment option for benign and malignant lesions Excellent safety profile and relatively easy to perform A low-cost procedure of short duration Less invasive and has a lower morbidity than some other surgical procedures Usually performed as an outpatient procedure Applicable for elderly patients with comorbid diseases that limit the ability to perform invasive surgery, and for pregnant patients Good to very good…

Electrosurgery

Chapter Summary Electrosurgery refers to thermal tissue damage resulting from tissue resistance to the passage of high-frequency, alternating electric current as in electrocoagulation, electrofulguration, electrodesiccation, and electrosection. Electrocautery refers to thermal damage from heat generated by an electric current. The precise tissue effect of electric current depends on current density, voltage, and electromagnetic waveform. Electrosurgery may be indicated for hemostasis and treatment of a variety of…

Wound Healing and Its Impact on Dressings and Postoperative Care

Chapter Summary Dressings cover the wound, absorb drainage, and provide a moist environment. Dressings should be selected to keep the wound moist, but not too wet nor too dry. Moist wound healing enhances epithelial migration, stimulates angiogenesis, helps in retention of growth factors, facilitates autolytic debridement and fibrinolysis, protects against exogenous organisms, and maintains voltage gradients. Healing of acute wounds is accelerated in a moist environment.…

Wound Healing

Chapter Summary Wound healing occurs in orderly, overlapping phases: the inflammatory, the proliferative, and the remodeling phases. The depth of the wound determines the degree of contraction and the location and source of keratinocytes that serve as a reservoir for re-epithelialization. Acute wounds created by a scalpel heal faster than wounds created by destructive or ablative methods. Platelets are the first cell to appear in the…

Antibiotics

Chapter Summary In general, the rate of wound infections in dermatologic surgery is extremely low. Given the frequency with which cutaneous procedures are performed, an understanding of skin microflora and risks of infection with procedures ranging from biopsies to liposuction is important. The rise of resistant bacteria in the population underscores the importance of a return to pathogen directed and evidence-based antibiotic use in dermatologic surgery.…

Patient Evaluation, Informed Consent, Preoperative Assessment, and Care

Chapter Summary Preoperative consultation should include the following elements: medical, surgical and social history, list of current medications, allergies, problem-focused physical examination, and explanation of any proposed procedure. Medical conditions may impact outcomes of cutaneous surgery, including pregnancy, hypertension, and cardiovascular disease. The potential risks, benefits, and alternatives of the proposed surgical procedure must be adequately discussed in order to obtain informed consent. Introduction The preoperative…

Instruments and Materials

Chapter Summary A dermatologic surgeon's skill depends upon knowledge of basic instrumentation and wound closure materials. Knowledge of the basic engineering principles such as stress–strain and basic metallurgy is an essential prerequisite to understanding instrumentation and materials. Investing in high-quality instruments that are practical for the range of procedures performed helps the dermatologist perform procedures with skill. Every instrument has proper uses and handling methods. Proper…

Anesthesia and Analgesia

Chapter Summary Most skin surgery can be performed under local anesthesia, avoiding the risks associated with general anesthesia. Local anesthetics reversibly interrupt propagation of nerve impulses by interfering with sodium ion influx into peripheral nerve cells. Topical application is particularly effective for mucosal surfaces because of their enhanced absorption. For other surfaces, intradermal or subcutaneous infiltration are the most commonly used techniques, the former being more…

Aseptic Technique

Chapter Summary In surgical procedures, there are four potential sources of contamination: the personnel, the surgical environment, the patient, and the instruments, with the patient's normal flora being the most common reservoir. Appropriate measures to ensure aseptic technique depend upon the procedure, the anatomical site of the surgical procedure, and the degree of contamination within the wound. There are basic precautions that should be adhered to,…

Anatomy for Procedural Dermatology

Chapter Summary Wound healing and the final surgical result depend on the anatomic location, structure of the skin and its functional interaction with underlying elements of the region. Anticipation of the dynamic tension exerted on free margins of the eyelid, nasal rim, helix of the ear, and lip helps in planning the procedure to preserve the regional anatomy. The cosmetic units of the face and skin…

Leprosy (Hansen’s Disease)

Description ■ Leprosy, or Hansen's disease, is a chronic infection caused by the bacteria Mycobacterium leprae. ■ The disease infects the skin and nervous system primarily, leading to visible skin lesions and autoamputation of the fingers and toes, and thus to disability and social stigmatization. ■ It is a common infectious disease in Asia, Africa, and Central and South America, affecting millions of people. History ■…

Leishmaniasis

Description ■ Leishmaniasis is a parasitic, protozoal infection transmitted by an arthropod bite and acquired in tropical and subtropical areas of the world. History ■ Leishmaniasis is caused by an intracellular infection by protozoa of the genus Leishmania. ■ The prevalence is estimated at 12 million people worldwide, with an annual incidence of 1.5 million worldwide. Roughly half of all new cases are in children. ■…